35-168 (8) 1339 BURTS PR RD BP-2019-1344
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block:35- 168 CITY OF NORTHAMPTON
Lot:-001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Buildina DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL c.142A)
Categmy. ROOF BUILDING PERMIT
Permit# BP-2019-1344
Project# JS-2019-002170
Eat.Cost:$4000.00
Fee:$40.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor: License:
Use croup: Homeowner as Contractor_
Lot Size(sa. R.1: 19994.04 Owner. CARVER JOHN R&CHARLOTTE
zoning: AAppUcanr CARVER JOHN R & CHARLOTTE
AT. 1339 BURTS PIT RD
Applicant Address: Phone: Insurance:
1339 BURTS PIT RD
FLORENCEMA01062 ISSUED ON:5128/2019 0:00:00
TO PERFORM THE FOLLOWING WORK.•STRIP & SHINGLE 3/4 OF ROOF
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rough: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeType: Date Paid: Amount:
Building 5/282019 0:00:00 $40.00
212 Main Street,Phone(413)587-1240,Fax:(413)587-1272
Louis Hasbrouck—Building Commissioner
Department use only
--'� City of Northa pto f Pe it
Building Depa en Curb ul)n away Perna
212 Main Str at MAY 2 4 2 r epti Availability
Room 10 Water all vailability
Northampton, 01 Two is of tructural Plans
phone 413-587-1240 F 41 -'�8�`r�,` ,�rNG IN` PI s
ON.MA 1
APPLICATION TO CONSTRUCT,ALTER,REPAIR,RENOVATE OR DEMOLISH A/ONE
/OORR TWO FAMILY DWELLING
SECTION 1-SITE INFORMATION
1.1 Property Addreaa: (� This section to be completed by office
,'3-391 avR� s T�..t „C4 Map �s Lot f 1/ Unit
"e C Y q Zone Overlay District
O / Om SL DYbiel CB Dmvkt
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
Se t~K 2. 0A 11111/ /?� 9 ✓.QHS �,r IZir�_
e( Cunem Mailing Address:
ray y�
r �
Telephone
Sig tore
2.2 Authorized Agent:
Name(Print) Current Mailing Address:
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed colt applicant
1. Building O n (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building PermH Feel
4. Mechanical(HVAC) sit v
5. Fire Protection t
6. Total=(1 +2+3+4+5) BOO , 9 O Check Number CIC,
This Section For Official Use Only
Ds
Building Permit Num r Date
Signature 5-zq-z6l9
Building Cgmmlestonernnapector of Buildings Data
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
f
Section 4. ZONING At Information Aust Be Completed. Permit Can Be Deni Due To Incomplete Information
Existing Proposed Required by Zoning
This column m be filled in by
Building Depn mt
Lot Size —_
Frontage
Setbacks Front ---
Side L R: L:_._._ R:
Rear
Building Height
Bldg.Square Footage
Open Space Footage -.....
(Lot area mivus bldg a paved
#of Parking Spaces
Fill:
volume a Laceaov
A. Has a Special Permit/Variance/Finding ever been issued for/on the site?
NO O DON'T KNOW O YES O
IF YES, date issued- ----- ---------
IF YES: Was the permit recorded at the Registry of Deeds?
NO O DONT KNOW O YES O
IF YES: enter Book Page and/or Document#
B. Does the site contain a brook, body of water or wetlands? NO O DON'T KNOW O YES O
IF YES, has a permit been or need to be obtained from the Conservation Commission?
Needs to be obtained O Obtained O , Date Issued:
C. Do any signs exist on the property? YES O NO O
IF YES, describe size, type and location:
D. Are there any proposed changes to or additions of signs intended for the property? YES O NO O
IF YES, describe size, type and location:
E. Will the construction activity disturb(clearing,grading,excavation,or filling)over 1 acre or is it part of a common plan
that will disturb over 1 acre? YES O NO O
IF YES,then a Northampton Storm Water Management Permit from the DPW is required.
SECTION 5- DESCRIPTION OF PROPOSED WORK(check all applicable)
New House ❑ Addition ❑ Replacement Windows Alteration(s) ❑ Rattling ❑
Or Doom ❑
Accessory Bldg. ❑ Demolition ❑ Naw Sig.. [OI Decks [E:J Siding lot Other[[31
Brief Description of Proposed �/ ,�
Work. %,,d 4&e o1 sktr' lel 4it �cas&E
Alteration of existing bedroom_Yes_No Adding new bedroom_Yes No
Attached Narrative Renovating unfinished basemen[ Yes No
Plans Attached Roll -Sheet
ea.N New hoose and or addition to existine housing, complete the following.
a. Use of building. One Family Two Family Other
b. Number of rooms in each family unit Number of Bathrooms
c. Is there a garage attached?
d. Proposed Square footage of new construction. Dimensions
e. Number of stones?
f. Method of heating? Fireplaces or Woodstoves Number of each
g. Energy Conservation Compliance. Masscheck Energy Compliance form attached?
h. Type of construction
I. Is construction within 100 ft.of wetlands?_Yes _No. Is construction within 100 yr. floodplain_Yes No
j. Depth of basement or cellar floor below finished grade
k. Will building conform to the Building and Zoning regulations? Yes No.
I. Septic Tank City Sewer Private well_ City water Supply
SECTION 7a-OWNER AUTHORIZATION-TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Dale
I, rr (L.V;;-52 as Owner/Authorized
Agent hiretry declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed unde(Na pains and pen es of perjury.
w Z . kTv rZ2
Frioa (�
/..
Signalu f Oaner/AgnM Date t
SECTION B•CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder'.
License Numoer
Address Expiration Date
Signature Telephone
9.Registered Home improvement Contractor: Not Applicable ❑
Company Name Registration Number
Address Expiration Data
Telephone
SECTION 10.WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§2SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
City of Northampton
r ✓'¢ Massachusetts
DEPAa1}ffiPl Or 9DIEDIM I1"in?Z rOna
212 win St[ t a l icipal euildi,y l p�
aortL to , rw 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes,a contractor most be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconstruction, alteration,renovation,repair,modamizafion, conversion,
improvement,removal,demolition, or construction of an addition to any preexisting cwneroccupied building containing
at least one but not mere than few dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has contracted with a corporation or LLC,that entity must be registered
Type of Work: Est.Cost:
Address of Work:
Date of Permit Application:
1 hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00
Owner obtaining own permit(explain):
_Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBH.ITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner:
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,l hereby apply for a building permit as the owner of the above property:
Ip 6 2`f 2(j l9
Date Owner Name and Signature
City of Northampton
Massachusetts
x
DEPt1NTNNNT OF BUILDING ZNSPYCTIONS
212 Main St-eat a M,nicipal Building r pCa
Northampton, MB 01060
Massachusetts Residential Building Code
Section 110.115.1.2
Homeowner: Person (s)who own a parcel of land on which he/she resides or intends to reside,
on which there is, or is intended to be, a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner.
Section I IO R5.1.3.1
Any homeowner performing work for which a building permit is required shall be exempt from
the licensing provisions of 780 CMR 110.115, provided that if a homeowner engages a person(s)
for hire to do such work, then such homeowner shall act as supervisor.
Such homeowner shall submit to the Building Official, on a form acceptable to the Building
Official,that he/she shall be responsible for all such work performed under the building permit.
As acting Construction Supervisor your presence on thejob site will be required from time to
time,during and upon completion of the work for which this permit is issued.
Also be advised that with reference to Chapter 152 (Workers' Compensation) and Chapter 153
(Liability of Employers to Employees for injuries not resulting in Death) of the Massachusetts
General Laws Annotated, you may be liable for person(s) you hire to perform work for you
under this permit.
City of Northampton
=.,
QL
MassachusettsOS BUILDING ZNSF=XONS212 Hain Str t *e nicip,i evilai�gg
xarlhaa n, HA 01060 �" B
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
133 �a"2L+f- ? kI
(Please print house number and street name)
Is to be disposed of at:
VA-U4-,N/ �l�
(Pleas not name and Tocation ofreality)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address) l^ -
aG:w lr OIQ -
Signa re of Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth of Massachusetts
Department of Industrial Accidents
7 Congress Street,Suite 700
Boston,b14 02714-2017
www.masi.gov/dia
R writers'Compensation Insurance Affidavit:Builders/Contraaors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Nmne(BusinesslOrgani,atioNlndividua0: r�
Address: 1324l,v rL`ES 'a `CJ
akez
City/State/Zip: ��.0 l�tti t_L bh k lePhone#:
Are you an employee cheek the appropriate box: Type of project(required):
1,0 l am a empbycr with employees lural anNor port-time)' 7. ❑New construction
2.❑I m a wlc pmpdeunorpwcrship and Mve m employees waiters forme in 8. ❑Remodeling
capcity.(No workers comp.waurana gnired]
J. 9. El Demolition
40 on a homeowner and will b,burn hacmra to conduct all work on 10❑Building addition
g con Y P'^PenY I will
are Nalall convacmrs either have wotken'comcemation insurance mare wle
11 Electrical repairs or additions
Popddon weds—mnployces, 12.❑Plumbing repairs or additions
501am.gereralconvac end IUse huedthe sub onbe on luded onthe attacked ahM.
Th13.❑Roofrepars
Thee,aubtiovtrxtors have employees and have workers'camp.immerse.:
6E we are a communist and its omen lave cremated thea right ofexcmpdon par MGL c. 14.❑Other
152,41141,andwe Mvcmemployees.[Nowodeers comp.imuranecre,dermil
'Any applicant Nm checks box#1 amt sato fill nut the section below showing Weir him sous'cocontin ion policy bait a new
'Gnrousi en who submit Wes affidavit indicatinghean
they are doing all work and Wen Aire outside cntracks rs most submit a new affidavit indicating such,
Konondors Nat check onesbus mustetWeMdmadditional Shenshowing Nenameoore sub-rnnnaclors and sate whether or wt Nnse rntitiv.have
employees. Ifthe submnvacmrs Mve employees,they must provide Wev workers'cam0.policy numbs.
I am an employer that is providing workers'compensation insurance for my employees. Below is rhe policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fore up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
!do hereby un/yderthey ns andpenddes of perjury that the information provided above is nue and correct
Si>;rlature' a^^ "r�e..����, k� ��r` Datc N's1�e't Zy 20
Phone 4LK>dY Z3j>dY Z3j—<
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Perswn: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned todhe city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or ifyou are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in_(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant a proof that a valid affidavit is on file for future permits or licenses. A new affidavit mus[be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address.telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street,Suite 100
Boston, MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-NIASSAFE
Fax# 617-727-7749
Revised 02-23-15 vv w.mass.gov/dia
Your Confirmation number is 201905249996939
Date of Confirmation:5/24/2019
NOTE:When paying by ACH(Checking)it will take two business days for the payment to be debited from your bank amount.Your
amount number is not verified until this payment is presented to your bank.They have the right to return this payment if unable to
process this transaction against your account.
Your request for payment(s)of$42.50 has been received and is subject to approval by your financial institution. No email was entered
so a confirmation was not sent.
Account Information Payment Information
Name: JOHN CARVER Payment Type: Credit Card
Note: QUICK PAY TRANSACTION Payer Name: JOHN CARVER
Card Number: """""""0796
Transaction Information
Transaction Quantity Amount Fee Payment Type
City of Northampton-Building 1 $40.00 $2.50 Credit Card
Department
Misc.QP
Permit Option:Building-Zoning-Sheet
Metal Permits
Full Name:John R Carver-1339 burtspit
rd-roof
Phone:
Email Address:
Notes:1339 BURTSPIT RD-ROOF
Total:$4250